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Obstetrics 3.

Postterm Pregnancy and Fetal Growth Disorders


OUTLINE
I. Postterm Pregnancy
II. Fetal Growth Disorders
a. Intrauterine Growth Restriction
b. Macrosomia

REFERENCES
1. Dr. Saluds lecture and PPT
2. Williams Obstetrics 24th Edition
NOTE: Unless otherwise specified, the information from this trans came
from the PowerPoint.

POSTTERM PREGNANCY
Delivery of a fetus at 42 completed weeks/294 days or greater from
the LMP
Factors affecting diagnostic accuracy:
o Wrong or unrecalled LMP
o Biological variations in menstrual cycle and ovulation dates
Confirmatory Test: Early Sonography
o To date pregnancy done
o Preferable in the 1st trimester
o Can also be done before the 24th week of pregnancy but error in
estimation is increased
Incidence: approximately 6% of 4 million infants born in the US are
born postterm
Predisposing factors
o Maternal

Prepregancy BMI >/= 25

Nulliparity

Prior Postterm
o Fetoplacental

Anencephaly no fetal head to help dilate the cervix

Adrenal hypoplasia

Placental sulfatase deficiency


Outcome of postterm pregnancies
o Uncompromised placental function which might probably lead to
continued fetal growth Macrosomia
o Placental dysfunction leading to postmaturity syndrome (10%)
o Perinatal mortality rates increase after the expected due date has
passed 2
Postmaturity Syndrome
o Wrinkled (particularly prominent on palms and soles), patchy,
peeling skin
o Long, thin body suggesting wasting
o Advanced maturity because the infant is open-eyed, unusually
alert, and appears old and worried
o Typically has long nails
o Looks like Benjamin Button
Associated pathophysiologic factors
o Loss of vernix caseosa
o Placental senescence with cell death leading to decreased fetal
oxygenation
o Oligohydramnios (10-33%) - scanty amniotic fluid, which can be
assessed by USG (Amniotic fluid index [AFI] 5)
o Cord compression with non-reassuring fetal heart rate patterns
(e.g. saltatory baseline)
o Scanty and viscous meconium which might lead to meconium
aspiration syndrome (most common indication for aggressive
management)
o Fetal growth restriction - stillbirths were more common among
growth-restricted infants who were delivered after 42 weeks; 33%
of postterm stillbirth infants were growth restricted

Group#28| Zabetty, Lea, and Mark Villanueva

Dr. Salud
September 18, 2014

Major causes of maternal and perinatal mortalities in postterm


pregnancy:
o Gestational HPN
o Prolonged labor with cephalopelvic disproportion
o Unexplained anoxia
o Fetal malformations
Specific causes of death
o Birth asphyxia
o Meconium aspiration
Pregnancy Outcomes
o Maternal

Increased rate of Cesarean Section

Intrapartum complications

Medical complications associated with gestational


hypertension and diabetes
o Fetal

Increased perinatal morbidity and mortality

Fetal distress

Shoulder dystocia for big babies

Neonatal Seizures

Increased admissions to neonatal intensive care

Increase in the number of long term developmental


anomalies and abnormalities

MANAGEMENT OF POSTTERM PREGNANCY


Management Controversies

Type of intervention and timing of use

The decision centers on whether labor induction is necessary or if


expectant management with fetal surveillance is best.

Acceptable indications of earlier intervention or delivery:


o Gestational hypertensive disorders
o Previous C-section
o Diabetes
o Oligohydramnios
o Fetal compromise e.g. saltatory patterns on electric heart rate
monitoring
Management Strategies

Induction of Labor
o Factors affecting success

Favourability of the cervix

Bishop score of 7 or more

Cervical dilatation

Cervical length (estimated by USG: < 3 cm or 25 mm long)

Station of the vertex (The Cesarean delivery rate was directly


related to station. It was 6% if the vertex before induction
was at 1 station; 20% at 2; 43% at 3; and 77% at 4)2
o Management of unfavourable cervix

Ripen with Prostaglandin E2 gel or Mifeprestone

Stripping of the membranes

Fetal Surveillance starting at 41 weeks


o Fetal movement counting at 2 hour period per day
o Nonstress test 3x per week
o Amniotic Fluid Volume estimation 2-3x per week

pockets < 3 cm is considered abnormal2


Management Recommendations

The American College of Obstetricians and Gynecologists defines


postterm pregnancies as having completed 42 weeks.2

There is insufficient evidence to recommend a management strategy


between 40 and 42 completed weeks. Thus, although not considered
mandatory, initiation of fetal surveillance at 41 weeks is a reasonable
option.2
Page 1 of 5

OBSTETRICS 3.3

After completing 42 weeks, recommendations are for either antenatal


testing or labor induction. Prostaglandins may be used for cervical
ripening or induction.2 (see Fig. 1)

FETAL GROWTH DISORDERS


Human fetal growth is characterized by sequential patterns of tissue
and organ growth, differentiation, and maturation
Factors involved in development:
o Maternal provision of substrate especially glucose
o Placental transfer of nutrients
o Fetal growth potential (genes)

Table 1. Three Phases of Cell Growth


PHASE
HYPERPLASIA
First 16 weeks
Increase in cell number
HYPERPLASIA + HYPERTROPHY
17-32 weeks
HYPERTROPHY
When most fetal fat and glycogen
are accumulated
After 32 weeks
When IUGR is best diagnosed
a see

Figure 1. Management of Post-term Pregnancy.


text on Management Strategies. b Prostaglandins may be used

Intrapartum Management

Treated as high risk pregnancy

Women whose pregnancies are known or suspected to be postterm


should come to the hospital as soon as they suspect labor. 2

While being evaluated for active labor, we recommend that fetal heart
rate and uterine contractions be monitored electronically for variations
consistent with fetal compromise.2

The decision to perform amniotomy is problematic. 2


o Further reduction in fluid volume following amniotomy can
certainly enhance the possibility of cord compression.2
o However it will aid in the identification of thickly stained
meconium, which may be dangerous to the fetus if aspirated
o Also, after membrane rupture, a scalp electrode and intrauterine
pressure catheter can be placed, which usually provide more
precise data concerning fetal heart rate and uterine contractions.2

Identification of thick meconium in the amnionic fluid is particularly


worrisome.

If you rupture the bag of water and there is thickly stained meconium
and very scanty amniotic fluid volume, you may do remedial measures.

Remedial measures for thick meconium and oligohydramnios


o Amnioinfusion

introduction of sterile NSS toward the intrauterine cavity


through the cervix to dilute the meconium

According to the American College of Obstetricians and


Gynecologists, amnioinfusion does not prevent meconium
aspiration, however, it remains a reasonable treatment
approach for repetitive variable decelerations2
o C-section should be strongly considered for thick meconium when
patient is remote from delivery

Especially when cephalopelvic disproportion is suspected or


either hypotonic or hypertonic dysfunctional labor is
evident.2

Management of Meconium Aspiration


o The American College of Obstetricians and Gynecologists does not
recommend routine intrapartum suctioning.2
o Alternatively, if the depressed newborn has meconium-stained
fluid, then intubation is carried out. The American Academy of
Pediatrics states that tracheal suctioning is neither supported nor
refuted.2

Group# 28 Zabetty, Lea, and Mark Villanueva|

DETERMINANTS
FETAL GENOME

ENVIRONMENTAL
NUTRITIONAL
HORMONAL

INTRAUTERINE GROWTH RESTRICTION (IUGR)


Low-birthweight infants who are small-for-gestational age (with
birthweights falling below the 10th percentile of weight expected for
gestational age)2
Birthweight may be affected by normal biological factors like ethnicity,
regional differences, parity, weight and height of parents

Figure 2. Smoothed Percentiles of Birthweight (g) for Gestational Age in the


United States. Based on 3,134,879 Singleton Live Births

They are at a higher risk for fetal morbidities and mortalities


o Fetal demise, birth asphyxia, meconium aspiration, neonatal
hypoglycemia
Postnatal prognosis of growth restricted fetuses is affected by:
o Causes of restriction

Restriction due to chromosomal, viral or maternal size


remains small throughout life (stunted growth)

Restriction due to placental insufficiency increase growth


and approach their growth potential (baby will catch up if
nutrition is good)
o Nutrition in infancy
o Social Environment
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OBSTETRICS 3.3
Classification (based on HC/AC ratio)

Symmetrical
o Reduced head and body size
o Usually occurs in infections
o Early insult - for example, global insults such as from chemical
exposure, viral infection, or cellular maldevelopment with
aneuploidy may cause a proportionate reduction of both head and
body size
o Results in decreased cell number and size

Asymmetrical
o Reduced body size
o Late pregnancy insult (e.g. placental insufficiency from
hypertension)
o Decreased cell size only
o Brain sparing normal head size and growth; most of the blood
will flow of the head which is more important than the body of the
fetus
Risk Factors

Constitutionally small mother


o <100 lbs 2x risk of delivering SGA infant
o When mothers want to maintain their sexiness

Poor maternal nutrition


o low BMI and poor weight gain especially in the 2nd trimester
o gestational weight gain during the second and third trimesters
that was less than that recommended by the Institute of Medicine
was associated with SGA neonates in women of all weight
categories except class II or III obesity2

Social deprivation
o lifestylesmoking, addiction, and poor nutrition

Maternal and fetal infection


o CMV direct cytolysis and loss of functional cells

most of these babies will not survive


o Rubella reduction in cell division and produces vascular
insufficiency

most will still be delivered

Congenital malformations
o the more severe the malformation the more likely is the fetal IUGR

Chromosomal Aneuploidies
o Trisomy 21mild IUGR
o Trisomy 18severe IUGR
o Trisomy 16fatal

Teratogens
o Anticonvulsants, antineoplastic

Vascular Disease
o superimposed pre-eclampsia
o chronic hypertension

Pre-gestational Diabetes
o Maternal vascular disease (fetal substrate deprivation)

Chronic Hypoxia
o Uteroplacental hypoxia: preeclampsia, chronic hypertension,
asthma, smoking, high altitude (those that live in high altitude are
usually smaller than those living in sea level)

Placental & Cord Abnormalities


o Chorioangioma, marginal or velamentous cord insertion,
circumvallate placenta
o This will lessen the flow of substrate oxygen to your fetus

Antiphospholipid Antibody Syndrome


o Adverse obstetrical outcomes including fetal-growth restriction
have been associated with three species of antiphospholipid
antibodies: anticardiolipin antibodies, lupus anticoagulant, and
antibodies against beta-2-glycoprotein-I
o Antibodiesmaternal platelet aggregation & plasma thrombosis
Group# 28 Zabetty, Lea, and Mark Villanueva|

Genetics
o Inheritance of certain substance that interfere with folate
metabolism
Multiple Fetuses
o The higher the number of fetuses in the mothers womb the
higher the chance it will affect the growth of the fetuses

Identification of IUGR

Fundic height measurement


o At 18-30 weeks, fundic height in centimeters should coincide with
2 weeks of gestational age
o Thus, if the measurement is more than 2 to 3 cm from the
expected height, inappropriate fetal growth is suspected

Sonographic Measurements
o 16-20 weeks for identification of anomalies
o 32-34 weeks for growth monitoring
o Establish the diagnosis of IUGR by:

Femur length

Biparietal Diameter

Abdominal Circumference (most commonly abnormal in IUGR


because soft tissue is involved)

Amniotic Fluid Measurement


o For determination of associated oligohydramnios

Doppler Velocity on fetal vessels with the following results:


o Umbilical Artery/ Middle Cerebral Artery abnormality

mild dysfunction

detects early changes in placenta-based growth restriction


o Ductus Venosus or Aorta Abnormalities

detects late changes

progressive dysfunction

Figure 3. Doppler velocimetry. (A) Normal velocimetry pattern with a


systolic to diastolic (S/D) ratio of <3. (B) The diastolic velocity
approaching zero reflects increased placental vascular resistance. (C)
During diastole, arterial flow is reversed (negative S/D ratio), which
is an ominous sign that may precede fetal demise.
Prevention

Preconceptional counseling on risk factors

Correction of nutritional deficiencies

Prophylaxis in early gestation with low dose aspirin (effective only in


10% of cases)
Management

Guidelines
o Confirm diagnosis
o Assess fetal condition by surveillance
o Evaluate for anomalies

34 weeks: Prompt delivery


o Vaginal delivery for reassuring Fetal Heart Rate (FHR) pattern
o Caesarean Section (CS) for non-reassuring FHR during labor
Page 3 of 5

OBSTETRICS 3.3

< 34 weeks
o Observation & monitoring until fetal maturity is attained
o Qualifications:

Normal fetus

Normal AFI (amniotic Fluid Index)

Normal fetal surveillance

Fetal growth continues


Management decisions must be based on relative risks of fetal death
with expectant management or risks from preterm delivery

For the American College of Obstetricians and Gynecologists,


elective delivery for the fetus that is suspected to be overgrown is
inadvisable, particularly before 39 weeks gestation. 2
Elective cesarean delivery is not indicated when estimated fetal
weight is <5000 g among women without diabetes and < 4500 g
among women with diabetes.2

Conduct of Labor & Delivery

High risk intrapartum monitoring

Watch out for fetal decompensation

Immediate care of the newborn for:


o Hypoxia
o Meconium aspiration
o Hypothermia
o Hypoglycemia

MACROSOMIA
Infants above the 90th percentile for a given age of gestation or
newborns weighing >4000g
o ACOG: Fetuses who weigh 4500g or more at birth
Risk Factors:
o Obesity
o Gestational diabetes and DM type 2
o Postterm gestation
o Multiparity
o Large size of parents
o Advancing maternal age
o Previous macrosomic infant
o Racial & ethnic factors
Diagnosis
o Sonographic fetal weight estimation - head, femur & abdominal
circumference

However, sonography can also make a mistake. If you are


going to assess the fetal weight at a later gestation, it should
be +/- 500g.

Routine use to identify macrosomia is not recommended

Findings of several studies indicate that clinical fetal-weight


estimates are as reliable as, or even superior to, those made
from sonographic measurements
o Clinical estimate by PE

Inaccuracy is often attributable to maternal obesity


Management
o Trial of Labor

Concern: possible shoulder dystocia resulting into brachial


plexus injury (brachial plexus palsy)
o Planned Cesarian Section

A reasonable strategy for diabetic women with estimated


fetal weight 4250g

planned cesarean delivery on the basis of suspected


macrosomia to prevent brachial plexopathy is an
unreasonable strategy in the general population2
o In summary, when fetal overgrowth is suspected, the obstetrician
naturally seeks to balance the risks to the fetus with maternal
risks. 2
o Although interventions to prevent shoulder dystocia may someday
prove beneficial, eliminating shoulder dystocia will likely remain
an impossible goal. 2

Group# 28 Zabetty, Lea, and Mark Villanueva|

Edited by: Venus Rojas

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Obstetrics 3.5

Postterm Pregnancy and Fetal Growth Disorders

Dr. Salud
September 18, 2014

Algorithm for management of IUGR at Parkland Hospital

Group#28| Zabetty, Lea, and Mark Villanueva

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